[Provider] Prior Authorization no longer required for certain codes

[Provider Notification]

ATTENTION:  Providers billing within Section 90 of the MaineCare
Benefits Manual

 

MaineCare's Physician Services rules (Section 90) recently changed.
Starting 3/29/2009, the procedure codes listed below no longer require
Prior Authorization (PA).  Even though PA is not required, the patient
must be medically eligible and the patient's records must support
medical necessity according to MaineCare policy guidelines for each
service.  Providers will be subject to post-payment audits for medical
necessity. Refer to Section 90 of the MaineCare Benefits Manual
<http://www.maine.gov/sos/cec/rules/10/ch101.htm>  for details about
medical criteria and eligibility.  

 

Service

Procedure Code(s) (including but not limited to)

 

Acne surgery

Blepharoplasty

Rhinoplasty/ Septoplasty/Septal Dermatoplasty

These procedures are NOT covered for cosmetic procedures

10040

15820, 15821, 15822, 15823, 67901, 67902, 67903, 67904, 67906, 67908

30400, 30410, 30420, 30430, 30435, 30450, 30465, 30520, 30620 

Circumcision

This procedure is NOT covered for routine, preventive, social, ethnic,
or religious reasons.

54150, 54160, 54161, 54162, 54164, 54000, 54001  

Hyperbaric Oxygen Therapy

99183

Sonohysterography

Hysterosalpingograms

These procedures are NOT covered for purposes of evaluation or treatment
of infertility. 

58340, 58345, 76831 

Penile Implant

These procedures are only covered after surgery for cancer, trauma, or
birth defects where pharmacologic treatments have failed. 

54405, 54400, 54401

Skin Tag Removal

This procedure is only covered when there is significant, ongoing
irritation or discomfort.

 

11200, 11201

 

   

More information is also available online at MaineCare's Procedure Code
Look-up <http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm>
and MaineCare's Prior Authorization website
<http://www.maine.gov/dhhs/bms/providerfiles/pa_inst_sheets_forms.html>
.  For questions about billing and claims, contact MaineCare Billing &
Information line at 1-800-321-5557 Option #8.  

 

Is your mailing address up to date with MaineCare?  Please keep
MaineCare up to date so your Remittance Statements and checks arrive on
time.  Call Provider Enrollment at 1-800-321-5557 Option #6.  

 

If you would rather not get these e-mails, visit MaineCare's List Serve
Subscription
<http://www.maine.gov/dhhs/bms/member/innerthird/listserv.shtml>  page
to unsubscribe.

 

This is a one-way communication.  Do not reply to this e-mail.  Your
e-mail will not receive response.  If you have questions, please call
1-800-321-5557.  

 

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